| Name:
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| Home
Address / Street:
|
City:
 State:
Zip
Code :
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| Home
Telephone :
Email
Address :
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| Belt
Rank / Color:
Male:
Female:
Age:
|
 School
Name :
|
| Emergency Contact (if not in attendance):
|
| Physician’s Name:
Physician's
Telephone :
|
| Last Tetanus Shot:
Can participant swim?:
yes
no
|
List all allergies:
|
Please attach a note of any health factors, which make it necessary for the participant(s) to follow a limited or restricted physical activity program at sea level. (I.E. recent surgery, allergies, diet, etc.) |
| Health Notes:
|
| |
| 2008 Summer Seminar Hold Harmless Clause |
I, the undersigned adult, on behalf of myself (and my child(ren) if any such child(ren) are registered as a Participant) agree to indemnify and to hold the Western Pacific Tang Soo Do Association, its affiliates, instructors, officials and agents, while acting within the scope of their duties, harmless from all lawsuits, causes of actions, demands, and claims, including costs of their defense, arising in favor of myself, my child(ren) participant (if applicable), or third parties, on account of personal injuries, death or damage to property arising out of the activities related to the above Summer Seminar activities.
|
| I
Agree Hold Harmless Clause:
I Disagree
to Hold Harmless Clause:
|
| I
Agree to Liability Waiver must be checked to participate
|
| Authorization for Medical Treatment |
| A parent or legal guardian must check “Authorization for Medical Treatment” before medical attention can be administered in the event of an emergency.
|
|
I give “Authorization for Medical Treatment”
I do not give “Authorization for Medical Treatment” |
| If you choose not to give “Authorization for Medical Treatment”, any other desired action must be specified in writing and signed in the space provided below. |
|
2008 Summer Seminar T-Shirt Order Form
No Charge for Participants—$15.00 for Non-Participants
Use this form for the entire order for your group
Sizes: S / MED / LG / XLG / XXL
Women sizes will probably run small, if not sure what size women's shirt to order; order a men's shirt. |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
| Name:
Men
Women
Size
Participant
yes
no |
|
|